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- Culture of Safety 2
- Education and Training 2
- Error Reporting and Analysis
- Human Factors Engineering 2
- Quality Improvement Strategies 2
- Technologic Approaches 1
- Identification Errors 1
- Medical Complications 3
- Medication Safety 3
- Surgical Complications 1
- Europe 3
- United States of America 9
Search results for "Error Reporting and Analysis"
Differences in strength expression on product labels of compounders and conventional manufacturers may lead to dosing errors.
Silver Spring, MD: US Food and Drug Administration; September 29, 2018.
Tools/Toolkit > Measurement Tool/Indicator
Washington, DC: National Quality Forum; December 2015.
The National Quality Forum (NQF) has been a leader in defining patient safety reporting measures. This website provides information about the third cycle of an NQF patient safety project that solicits new measures and will review existing patient safety metrics. The deadline for submitted appeals on the 13 endorsed measures was February 28, 2017.
Avery L, Bennett R, Brinsley-Rainisch K, et al. Atlanta, GA: Centers for Disease Control and Prevention; October 9, 2018.
Improving the Measurement of Surgical Site Infection Risk Stratification/Outcome Detection: Final Contract Report.
Price CS, Savitz LA. Rockville, MD: Agency for Healthcare Research and Quality; March 2012. AHRQ Publication No. 12-0046-EF.
This report explores techniques to detect and monitor surgical site infections (SSIs), evaluates a computer-assisted algorithm to identify patients at risk for SSIs, and makes recommendations to investigate surgery-specific risk factors.
Levinson DR. Washington, DC: US Department of Health and Human Services, Office of the Inspector General; March 2010. Report No. OEI-06-08-00221.
This report examined five methods of identifying adverse events that harmed hospitalized patients. Findings note that physician and nurse reviews were highly effective in discovering problems but that incident reports were not as useful. The document provides numerous recommendations to improve screening for adverse events.
Tools, Methods, and Techniques for Improving Patient Safety: Patient Safety Improvement Corps Training DVD.
Rockville, MD: Agency for Healthcare Research and Quality; 2007.
This DVD provides training modules for health care professionals regarding systems-oriented, institutional improvements in patient safety.
Journal Article > Government Resource
Centers for Disease Control and Prevention. MMWR Morb Mortal Wkly Rep. 2006;55:1016-1017.
This article reports on an investigation into clusters of mistakes involving the misadministration of a vaccine.
Scobie S, Minghella E, Dale C, Thomson R, Lelliott P, Hill K. London, UK: National Patient Safety Agency; July 2006.
This report, the second in a series from the United Kingdom's National Patient Safety Agency, analyzes nearly 45,000 patient safety incidents relating to mental health that were reported to a nationwide incident reporting system. The majority of reported incidents were from inpatient mental health facilities, primarily involving patient accidents (including falls), disruptive or aggressive behavior, self-harming behavior, and missing (absconding) patients. The report summarizes existing initiatives to improve patient safety in mental health, makes specific recommendations for mental health providers, and identifies priority areas for future research.
Tools/Toolkit > Government Resource
Manchester, UK: University of Manchester; 2006.
This tool was developed to help National Health Service organizations assess their progress in implementing and sustaining a safety culture.
Scobie S, Thomson R. London, England: National Patient Safety Agency; 2005.
Created in 2001 to institute changes in health care across the United Kingdom, the National Patient Safety Agency (NPSA) presents their first report of patient safety incidents. The two-part report begins with a general discussion of incident reporting, the basis for a national reporting system, and the development of the Patient Safety Observatory. The second part builds on this framework by discussing how the acquired data can be used and translated into safer health care strategies. The report itself encompasses more than 85,000 collected incident reports with analysis, comparisons, and case studies to illustrate important safety issues for future efforts. This represents the first of a series of expected reports from NPSA on patient safety data to be published.
PHC4 Research Brief. Harrisburg, PA: Pennsylvania Health Care Cost Containment Council (PHC4); July 2005.
This report summarizes hospital-acquired infection data from Pennsylvania hospitals in 2004 and indicates that the number of such infections has likely been underreported.
Rockville, MD: Agency for Healthcare Research and Quality; March 2007.
The Agency for Healthcare Research and Quality announces the 2007–2008 Patient Safety Improvement Corps (PSIC) program. States and organizations participating in the program will select staff members and its hospital partners to train in patient safety improvement. The applications period for this program cycle is now closed.